A well-respected healthcare lawyer from Los Angeles has raised his voice against the USA’s prevailing ER care reimbursement and administration system. Every emergency room of a hospital in the land is under a legal obligation to treat any patient who comes to it even if the healthcare plan of this patient is not under a contract with the hospital. However, the whole system is very expensive, irrational, and unnecessary when it comes to the reimbursement process.
Gregory Pimstone explains why the system is inefficient
Gregory Pimstone is an esteemed healthcare lawyer from Los Angeles and is the head of the healthcare law group at national law firm Manatt in the USA. He is currently advocating the need to execute significant changes to America’s prevailing ER care reimbursement system.
In order to understand the problem better, one should understand how the present system works. When a person has been injured, the law of the land permits them to go to the nearest ER, even if it is not contracted in the patient’s health plan. The law requires medical providers to treat the injured patient till he/she is stabilized. The law also lays down that the health plan of the patient will pay for the care rendered. The plan cannot direct any insured person under it to go to contracted ERs or refuse to offer coverage for services rendered by non-contracted emergency providers.
All of the above make clear sense if you look at it from a public perspective. Now, the real question surfaces- what happens when the ER care provider and the health plan carrier do not agree to the reasonable costs for the service? The end result is a series of legal disputes that land up in courts of law, clogging the whole judiciary system of the land.
The entire process is expensive and just a waste of precious resources
He says that when these suits land up in court, there are huge expenses incurred when sharing electronic information and legal fees. Every case is different, and the rate data and payment deployed in one legal dispute often differs from the information derived from another hospital. As the law has not determined any set formula for fixing the reasonable value, a jury, judge, or arbitrator of a court of law might come up with varied conclusions, even after using the same information exactly to determine the value of ER healthcare services.
Gregory Pimstone of Manatt says this is where the root of the problem lies. It can only be resolved if the California Legislature takes up the issue and determines a set formula for calculating the fair costs of healthcare services rendered to a patient in any ER care unit.
He sums up by saying, “The problem is not going away: patients show up every day in ERs around the state that are not in their insurer’s network. We can either have a system that requires providers and carriers to lawyer up and duke it out each time in court, arguing vague standards. Or we can decide to address the issue with something definite and conclusive and put our resources to better use.”